Fluoroquinolone-induced liver injury: three new cases and a review of the literature

Toxicity induced by ciprofloxacin and enrofloxacin: oxidative stress and metabolism

Ciprofloxacin (CIP) (human use) and enrofloxacin (ENR) (veterinary use) are synthetic anti-infectious medications that belong to the second generation of fluoroquinolones. They have a wide antimicrobial spectrum and strong bactericidal effects at very low concentrations via enzymatic inhibition of DNA gyrase and topoisomerase IV, which are required for DNA replication. They also have high bioavailability, rapid absorption with favorable pharmacokinetics and excellent tissue penetration, including cerebral spinal fluid. These features have made them the most applied antibiotics in both human and veterinary medicine. ENR is marketed exclusively for animal medicine and has been widely used as a therapeutic veterinary antibiotic, resulting in its residue in edible tissues and aquatic environments, as well as the development of resistance and toxicity. Estimation of the risks to humans due to antimicrobial resistance produced by CIP and ENR is important and of great interest. Moreover, in rare cases due to their overdose and/or prolonged administration, the development of CIP and ENR toxicity may occur. The toxicity of these fluoroquinolones antimicrobials is mainly related to reactive oxygen species (ROS) and oxidative stress (OS) generation, besides metabolism-related toxicity. Therefore, CIP is restricted in pregnant and lactating women, pediatrics and elderly similarly ENR do in the veterinary field. This review manuscript aims to identify the toxicity induced by ROS and OS as a common sequel of CIP and ENR. Furthermore, their metabolism and the role of metabolizing enzymes were reported.

Development of a signal-enhanced LFIA based on tyramine-induced AuNPs aggregation for sensitive detection of danofloxacin

A signal-enhanced LFIA based on tyramine (TYR)-induced AuNPs aggregation has been developed for the sensitive detection of danofloxacin (DAN). In the model, the hydroxyl radical produced by HRP catalyzing H₂O₂ can trigger the TYR-AuNPs to aggregate on the T or C line for enhancing the detection signal. The linear range of TYR-AuNPs LFIA was 0.25-5 ng mL^-1 with the limit of detection (LOD) of 0.032 ng mL^-1, and the LOD was 8-fold lower than that of the traditional AuNPs LFIA (0.26 ng mL^-1). The TYR-AuNPs LFIA could be used with the naked eyes to qualitatively detect DAN with a cut-off limit of 2.5 ng mL^-1, which was 4-fold lower than that of the traditional AuNPs LFIA (10 ng mL^-1). The recoveries of TYR-AuNPs LFIA were 86.04-105.14% and 92.41-110.19%, with the coefficient of variation of 1.71-2.05% and 4.42-5.89% in chicken and pork, respectively.

Hepatotoxicity Secondary to Levofloxacin Use

Levofloxacin is a broad-spectrum antibiotic that is used in the treatment of many infections. A rare adverse drug reaction following the use of levofloxacin is drug-induced liver injury. The exact mechanism behind fluoroquinolone-induced liver injury is unknown, but many severe, sometimes fatal hepatotoxicity cases are reported. Current recommendations advise clinicians to discontinue levofloxacin immediately if the patient develops signs and symptoms of hepatitis. This case report presents a 79-year-old male who was prescribed levofloxacin 500 mg by mouth daily for seven days. The patient had a past medical history of dementia, seizures, cerebral vascular accident, pulmonary fibrosis, and chronic kidney disease. Upon admission, the patient began to show signs and symptoms of liver injury. We hereby present a case report and a review of significant literature on levofloxacin-induced liver injury.

Liver proteome analysis of grass carp (Ctenopharyngodon idellus) following treatment with enrofloxacin

Enrofloxacin is widely used for the prevention and control of bacterial diseases in aquaculture. The liver is crucial for enrofloxacin metabolism, but enrofloxacin can induce liver damage. Herein, we explored proteomic changes in the liver of grass carp (Ctenopharyngodon idellus) following treatment with enrofloxacin using isobaric tag for relative and absolute quantitation (iTRAQ) technology. All experiments included two biological replicates and blank controls. Among the 3082 proteins identified, 103 were differentially abundant, comprising 49 up- and 54 downregulated proteins. Gene Ontology (GO) annotation identified macromolecular complex (63.60%), intracellular non-membrane-bound organelle (51.50%), and non-membrane-bound organelle (51.50%) as the most enriched cellular component terms. Structural molecule activity (26.80%), structural constituent of ribosome (17.90%), and calcium ion binding (16.10%) were the top three molecular function terms. Organic substance biosynthetic process (37.80%), biosynthetic process (37.80%), and protein metabolic process (37.80%) were the top three biological process terms. The Kyoto Encyclopaedia of Genes and Genomes (KEGG) pathway analysis found 17 enriched KEGG pathways, with protein digestion and absorption, extracellular matrix (ECM)-receptor interactions, and ribosome and focal adhesion the most significant (p < 0.001). Analysis of the most enriched pathways revealed that chymotrypsin-like precursor, pancreatic elastase precursor, Na+/K+ transporting ATPase, collagen, and dermatopontin were upregulated, while ribosomal proteins, alpha-actinin, and myosin light chain were downregulated. These findings suggest that enrofloxacin affects liver function and has a risk of inducing an inflammatory response in extrahepatic organs.

Incidence, clinical features, and risk factors of fluoroquinolone-induced acute liver injury: a case-control study

Background

Fluoroquinolone-related hepatotoxicity is rare but serious and is attracting increasing attention. We explored the incidence, clinical features and risk factors of acute liver injury associated with fluoroquinolone use.

Materials and methods

Based on the Adverse Drug Events Active Surveillance and Assessment System that we developed, we carried out a case-control study by enrolling patients who were hospitalized and received fluoroquinolones to treat or prevent infections at the Chinese People's Liberation Army General Hospital from Jan 2016 to Dec 2017. The incidence of fluoroquinolone-induced acute liver injury was estimated, and logistic regression was used to reveal the risk factors of this adverse reaction.

Results

We found that 17,822 patients received fluoroquinolones, and 13,678 of them met the inclusion criteria. A total of 91 patients developed acute liver injury after receiving the medication, and 369 controls were matched to these patients. The overall incidence of fluoroquinolone-induced acute liver injury in the Chinese population is approximately 6-7 cases per 1,000 individuals annually. Multivariate logistic regression analysis showed that older age slightly decreased the risk of hepatotoxicity (OR, 0.98; 95% CI, 0.96-0.99). The male sex (OR, 2.19; 95% CI, 1.07-4.48), alcohol abuse (OR, 2.91; 95% CI, 1.39-6.11) and hepatitis B carrier status (OR, 2.38; 95% CI, 1.04-5.48) increased the risk of liver injury. Concurrent use of cephalosporins or carbapenems was also associated with an increased risk.

Conclusion

Increased risk of fluoroquinolone-related hepatotoxicity may be associated with youth, the male sex, alcohol abuse, hepatitis B carrier status and the concurrent use of cephalosporins or carbapenems.

Long-Term Risk of Cardiovascular Death With Use of Clarithromycin and Roxithromycin: A Nationwide Cohort Study

Recent studies have raised concern that macrolide antibiotics may be associated with an increased long-term risk of cardiovascular death. We examined the 1-year risk associated with treatment with clarithromycin (n = 187,887) or roxithromycin (n = 698,899) compared with penicillin V (n = 3,473,081), matched 1:4 on propensity score, in a nationwide, registry-based cohort study in Danish outpatients, 1997-2011. Among clarithromycin courses, the rate ratio for cardiovascular death was 1.24 (95% confidence interval (CI): 0.96, 1.59). Among roxithromycin courses, the rate ratio was 0.99 (95% CI: 0.86, 1.16). In analyses by time after treatment start, the rate ratio associated with clarithromycin was 1.66 (95% CI: 0.98, 2.79) during days 0-7. This was attenuated in later time periods (days 8-89, rate ratio = 1.30, 95% CI: 0.88, 1.94; and days 90-364, rate ratio = 0.96, 95% CI: 0.63, 1.47). For roxithromycin, the rate ratios were 0.88 (95% CI: 0.59, 1.32) during days 0-7, 1.17 (95% CI: 0.92, 1.48) during days 8-89, and 0.88 (95% CI: 0.70, 1.10) during days 90-364. We found no increased risk of cardiovascular death in a general outpatient population. With clarithromycin, we observed a transient increased risk during days 0-7 after treatment start, which corresponds to the period of active treatment. This association was absent in later time periods, which is consistent with no long-term toxicity resulting in cardiovascular death.

Adverse drug reactions and organ damage: The liver

Drug-induced liver injury (DILI) is among the most challenging acute or chronic liver conditions to be handled by physicians. Despite its low incidence in the general population, DILI is a frequent cause of acute liver failure. As such, the possibility of DILI should be considered in all patients who present with acute liver damage, independent of any known pre-existing liver disease. DILI can be classified as intrinsic/dose-dependent (e.g., acetaminophen toxicity) or idiosyncratic/dose-independent, with the latter form being relatively uncommon. Amoxicillin-clavulanate is the antimicrobial that is most frequently associated with idiosyncratic DILI. Large, ongoing, prospective studies in western countries have reported other drugs associated with DILI, including nonsteroidal anti-inflammatory drugs, statins, and herbal and dietary supplements. An important safety issue, DILI is one of the most frequently cited reasons for cessation of drug development during or after preclinical studies and for withdrawal of a drug from the market. This review summarizes the epidemiology, risk factors, commonly implicated drugs, clinical features, and diagnosis of DILI, with the aim of aiding physicians in the management of this debated problem. Old and new biomarkers for DILI and pharmacogenetic studies are also described.